GW1-2021-02027_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
r / 14.WATER ZONES
�e`y,(q^ FROM TO DESCRIPTION
Well Contractor Name ft it. /
n D ?/ rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ira licable
FROM TO DIAMETER THICKNESSr MATERIAL
ka
• Lr mLtl//^� �it�QL� �//``//lam L�C �'[ ft. ! ft l in. r2S
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
^ - �� FROM TO DIAMETER TTHCKNESS MATERIAL
2.Well Construction Permit#: O/` ft• ft. in.
List all applicable well construction permits(i.e.County.State. Variance,etc.) ft. ft
in.
3.Well Use(check well use): 17.SCREEN
Water Supply W011: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l�sidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation
Non-Water Supply Well:
rc. rt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tcolor,hardness,sosUrock e, rain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. �t. WZ,. 5
ft. ft.
4.Date Well(s)Completed: S - o? ft rt.
5.Well Location: ft. ft.
ft ft. J Ad
Facility/Owner Name Facility ID licable)
rt. rt inforr atlon Processing Ullit
dt Q ft. ft.
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN) r SS
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
sy , �SSaU N S�6 W G S -r7ao.z/
tgnature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this forin. I herebv certifi that the well(s)was(were)constructed in accordance
__ With 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: li,<S or ❑No copy oj'this record has been provided to the ivell owner.
If this is a repair,Jill out known well construction information and ewplain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
/ You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: Ol S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: _3 S (ft.) Division of Water Quality,Information Processing Unit,
/f water level is above casing,use"+"! 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Malty construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test:_ 3 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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